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Scans for Back Pain Ineffective

By Tara Parker-Pope February 6, 2009 3:38 pmFebruary 6, 2009 3:38 pm

Patients suffering from lower back pain often undergo X-rays or imaging scans to detect the source of the problem. But new research shows scanning to find the source of back pain may do more harm than good.

Researchers from Oregon Health and Science University in Portland reviewed six clinical trials comprised of nearly 2,000 patients with lower back pain. They found that back pain patients who underwent scans didn’t get better any faster or have less pain, depression or anxiety than patients who weren’t scanned. More important, the data suggested that patients who get scanned for back pain may end up with more pain than those who are left alone, according to the report published this week in the medical journal Lancet.

About two thirds of adults suffer from low back pain at some time in their lives, and low back pain is the second most common symptom that sends people to the doctor (upper respiratory problems are first). Studies suggest that more than half the patients who see a doctor for back pain undergo X-rays or another imaging study as a result.

The problem, say researchers, is that back scans can turn up physical changes in the back that aren’t really causing any problem. One well known study from The New England Journal of Medicine put 98 people with no back pain into a magnetic resonance imaging scan. Even though all of them had healthy backs, two out of three of them came back with M.R.I. reports that showed disk problems.

“You can find lots of stuff on X-rays and M.R.I.’s like degenerative disks and arthritis, but these things are very weakly correlated with low back pain,” said study author Dr. Roger Chou, associate professor of medicine at Oregon Health. “We think we’re helping patients by doing a test, but we’re adding cost, exposing people to radiation and people may be getting unnecessary surgery. They start to think of themselves as having a horrible back problem and they stop doing exercise and things that are good for them, when in reality, a lot of people have degenerative disks and arthritis and have no pain at all.”

Dr. Chou said patients should ask their doctors why a scan or X-ray is needed rather than using pain relief and exercise to cope while a back heals on its own. Most back pain gets better within 30 days if a patient takes normal precautions after a pain episode. If back pain persists for longer than a month, or if symptoms suggest a more serious problem like an infection or tumor, then an X-ray or scan may be needed, Dr. Chou said.

“I think patients should question whether they really need it,” Dr. Chou said. “From a societal perspective, it’s important because we’re wasting a lot of money that could be used for better purposes. But from an individual patient’s perspective, doing X-rays and M.R.I.’s can lead you down a path that you don’t want to go down.”

Lower back pain scans are almost as worthless as lower back surgery, but if you lose control over your foot action, regardless of pain, call a doctor. Learn how to sit, rise, and stand correctly and keep your back and abdominal muscles strong.

Hard to figure how people get worse with scanning. (And Dr Chou seems puzzled, too.) I’ve had a lot of trouble and always been told that I’m not a candidate for surgery or any aggressive treatment; short-term rest, and then physical therapy; that my problems may be painful without being serious. So maybe I’ve been lucky in my choice of doctors.

I believe that the problem is not the diagnostic tools. Rather it is the excessive fees associated with using them. In my case, an MRI of my back revealed the cause of my pain, a synovial cyst. PT and time took care of it. Personaly I had rather have prrof of a condition rather than an assumption of what it could be.

there is a doctor in new york who has written about the mindbody connection with back pain. he was docmented on TV’s 20/20 and has said the same thing for years: that manyof the problems doctors see on mri’s & xrays have little or no connection to back pain. This knowledge changed my life after years of terrible back problems- putting this in perspective and using a good chiropractor and back pain does not seem so uncontrolable.

This is an extremely interesting post on several levels. Anyone reading the political articles in the New York Times these days knows that President Obama ,as part of the stimulus bill, included funding for comparative outcomes research for various medical procedures. Had this program been funded, hundreds of ineffective procedures such as scans for lower back pain would be identified and then eliminated, saving hundreds of millions of dollars and improving everyone’s health. Of course the Republicans eliminated this provision from the bill.

Secondly, the fact that treatments for lower back pain are so ineffective raises an interesting point about the problem of medical research in this country. The federal government (through the NIH) and drug companies spend billions of dollars developing “me too” drugs and therapies for conditions for which adequate treatment options already exist. But little if any attention is paid to developing new therapies for conditions that could dramatically improve people’s lives. Things like balance problems in the elderly and lower back pain cause tremendous amounts of pain, disability and even death yet the biomedical research establishment devotes very few resources to these problems. Yet no one thinks twice about spending untold sums to develop yet another blood pressure medication or anti-histamine. This needs to change.

Finally it’s time to face the reality that improvements in diagnostic technologies are doing as much damage as good. Whether its PSA testing that results in morbidity to patients because clinically irrelevant tumors are being removed or CT- Scans and MRIs for lower back problems, unless the sensitivity of these diagnostic tools can be improved, they probably shouldn’t be used.

Sometimes you have to wonder, are doctors curing more patients or hurting more patients?

You cannot lump all of back pain into one group. It is irresponsible. As a chronic back pain sufferer and Radiologist who reviews thousands of spine studies every year, I believe that every patient with back pain deserves an attempt to find a surgically correctable condition. There is more to back pain than just a disc herniation/disc bulge/disc degeneration. If even a small percentage of patients have a treatable cause for their pain, the benefits are certainly worthwhile for them. My surgery 3 years ago transformed me from someone who could not walk more than 15 minutes to someone who can walk as far as I want. My pain may not be totally gone, but it is easily managable, and that has made all the difference.

Someone I know interviewed a back doctor at one point who said one reason to perform surgery for back pain was that it was often the only way to get the patient physical therapy – and that was what he felt really fixed the back pain. I myself have a back that for years was weak and prone to severe spams, the kind that would put me in bed for days at a time. Taking Pilates lessons cleared that all up. I am pain free and spasms rarely threaten. When they do, anti-inflammatories keep them at bay.

I disagree with discouraging scans. I had severe back and sciatic pain as a college student — the campus doctor gave me pain pills of ever-increasing strength and sent me to physical therapy. After graduation, a private practice doctor took an x-ray, then a CT scan, and found the pain was caused by a aggressive tumor. Luckily, surgery was effective.

I don’t see any reason to deprive a doctor of information. To discourage scanning is to encourage cutting corners in health care.

This is a ridiculous study and not very helpful overall. For about eight years I’ve had intermittent lower back pain and in the past six months it has gotten more frequent. I don’t believe any of us should be like docile sheep with our doctors and my general practitioner knows and appreciates this about me, even when I differ with him. In fact, I had to firmly request an MRI because I know my own body than anyone else and knew there was a problem, I just didn’t know the cause. He didn’t think it was necessary but did authorize the scan. Of course, the MRI showed that I have a herniated disc in my # 5 lumbar vertabra which is pinching on my left foraminal nerve. Now I know what is causing the problem and am able to manage the frequency and intensity of the pain based on proper treatment. To suggest that these diagnostic tests are not beneficial sounds like the wrong type of cost efficiency, with again, the patient left to parse all of the contradictory studies out there, including this one.

As a long term sufferer with back pain and arthritic degeneration I read your article with interest. It is important to measure the implications of all the procedures we go through to establish that they are doing more harm than good. However I am under the impression that most people don’t go to see a doctor at the first signs of lower back pain. Someone please correct me if that is a false impression. Imaging has played an important role for me in dealing with my body and more importantly it has helped to guide the healthcare professionals (including physical therapists) who help me.

Incapacitated for 30 days by almost unbearable pain which is eased, yet not eliminated by potentially addictive drugs such as oxycodone, vicodin and morphine will most likely result in a patient who will do/try almost anything to improve their situation. I30 days is a long time. It seems hard to believe that the only option available is to medicate and wait the torture out. Trust me, my husband had to have the epidural to be in the delivery room with me for the birth of our second child. He ate Thanksgiving dinner of the same year lying on the diningroom floor woozy from morphine. We decided to do whatever was necessary to try and improve a horrible situation that kept recurring. Yes, it started with x-rays and scans, yes, they revealed degenerative disc disease and herniated discs. We don’t know if that’s what caused the excruciating pain, nor are we sure of what has kept it at bay for almost four years now.

I will tell you what we did, though. In spite of my skepticism, and barely subsidized by our insurance, my husband underwent a course of non-surgical spinal decompression at a chiropractor’s office. We sold our house and moved to eliminate an hour driving commute (adding $1200/month to our housing cost). He took up cycling again and is devoted to regular excercise. The result, as they say, is priceless. He is healthy and practically pain free and has been for almost 4 years.

I can’t say whether or not the scans are of any benefit, but I can certainly understand why anyone suffering from back pain would want to explore any avenue open to them. You never know where you will find an answer.

As a raiologist, I agree that most scans for back pain are unnecessary because most back pain is not caused by structural problems like herniated discs or pinched nerves. Most back pain is muscular and due to fatigue and spasm casued by poor use. How we go about our usual daily activity may put unnecessary strain on the muscles of our backs, which I believe is the most common cause of pain. Surgery does nothing to change our bad habits, and therefore does not stop the real cause of pain. That is why many people have recurrent pain after surgery. The real issue with back pain is that people need to learn how to use their back efficiently and effectively and scans and surgery do not do that.

From my own experience it was Physical Therapy that improved my lower back pain more than anythng. I could ‘t get the PT treatment until I had the MRI, however, and then my insurace co. only pays for a limited amount of sessions per year. PT is a much cheaper option than surgery so you would think that the insurance companies would be all for it. Saddly this is not the case.

I have been diagnosed with degenerative disc “disease” for over a decade now. I’m a very active 38 year old male.

I’ve had MRIs done almost every other year for ten years and the scans do show successive degeneration. After alternative therapies (PT, acupuncture, etc), and pain management with drugs, I plateaued and began losing strength in my right leg. I finally decided on surgery because the scans showed root nerve impingement at L4-L5 and L5-S1, these were decompressed and all the pain and weakness disappeared, and no more daily cocktail of oxycontin, soma, valium and 800mg ibuprofens.

However, the scans also showed that it was beginning to happen to my left as well…and now what happened to my right is happening to my left side – first episodes of pain, inability to walk due to sciatice, but no weakness – yet. When that happens, you have to have surgery, there is really no other alternative. Thus, I’m a bit skeptical of this new study. I’m sure there are countless reasons for back pain, but mine is clear cut – my discs are gray to black – meaning hardly to no fluid at all in them which cause nerve pinching and impingements.

I have a neighbor who has been in agony for more than two months. Because she goes to an HMO they refuse to do anything. She practically weeps from the pain. Yes, they are cutting costs. Yes, it’s no skin off their nose if she is in agony.
If it delays treating something treatable, there is no punishment. They can kill her and get away with it. And in every case, where doctors are given a choice (as a group) between treating patients and saving money (for a good cause, even for themselves) they will save the money. Read “Nazi Doctors”.

Probably the most important thing I learned from my neurosurgery and outpatient medicine rotations was: STAY AWAY FROM THE KNIFE unless absolutely necessary. The back surgery itself is totally brutal, and many times patients end up worse off then they were to start. I really felt for those patients the day after surgery. Nobody in the hospital had more pain than they did.

I am stunned that you can discuss back pain and not mention chiropractors. I know many people, myself included, who went the round of multiple MD’s at different hospitals and xrays that showed “nothing” they could do, followed by a trip to a chiropractor who fixed the problem in 10 minutes.

I believe in California, it is now required to get a chiropractor’s opinion on back pain cases, and they work routinely in the Emergency Department along with MD’s.

On the flip side, a very good friend did not see a chiropractor, went in for surgery, and was basically consigned to back pain for life by a botched procedure.

Given the costs and risks, chiropractors should be very early in the diagnosis process. Good ones will send you to the MD’s if they see something they are not equipped to deal with. There ARE good ones.

I have found the reverse to be true. I have suffered from chronic low (l5-s1) back pain for many years. I have had x-rays and mris only to be told they can find no cause for my pain so it must be all in my head. It is very patronizing, condescending and painful.

From a doctor’s perspective, a test should never be ordered unless (a) you know what you’re looking for; (b) you know what to do with the information gleaned from the test; (c) the test itself is expected to do more good than harm; (d) the results of the test are likely to change the treatment approach; and (e) the patient is educated about the limitations of testing and the risk of uncovering a “red herring,” the treatment of which may either prolong or worsen his/her pain.

As someone who treats many back injuries each year, I encounter lots of patients who request MRI scans without considering their downsides. My first job is to educate myself on the predictive vaue of the test. My second job is to educate the patient in language they can understand why the test may or may not be healpful. And third (most importantly), I have to sit down with the patient and explain the test results themselves, and reason why I think the test results are either relevant to their pain or not.

There have been may books written on low back pain, but the limits of our knowledge remain humbling.

Many of the commenters are missing a major point to the study and the article. Long term issues with the back should be scanned. But wait 30 days, unless there are symptoms that clearly point to things like a tumor. Most problems are muscular, and are not going to show up on a scan, and are going to go away with proper therapies and rest.

Most of the people objecting to this study have had very long term problems, and scans told them what was wrong. That is great, that is what the scans are good for. But just throwing medical procedures at every problem, no matter the cost or exposure to dangerous stuff, is a recipe for personal and society disaster.

Studies which make generalizations such as “Scans for Back Pain Ineffective” are dubious at best.

Many people experience back pain. And, thankfully, most back pain resolves on its own, requiring no surgery or epidural injections. However, a scan may be be necessary, because there are a small percentage of cases that do require intervention. I happen to fall into that category. Twice in my life I have had debilitating back pain. The first time 15 years ago I was incapacitated for months. I was told that even my case would eventually resolve in a year or two. Not wanting to wait that long I had surgery for a disc herniation by a top surgeon in Boston. I walked pain free that night. I then went on to have 2 babies with no complications. Then 3 years ago, I had another episode of unbelievable pain. The morphine in the ER did not even work This time I was told that surgery is very rarely recommended these days. I was evaluated by a top pain clinic in Boston, and had an epidural steroid injection for a disc herniation. This worked. I continue to have no pain.

I have been lucky. There are many people with unresolved back pain and my heart goes out to them.

One commonly overlooked source of lower back pain, especially in males in their early to mid-20’s is ankylosing spondylitis, a form of arthritis that tends to impact the sacroiliac joints and lumbar spine. Left untreated, it can cause permanent deformity and disability. People with untreated AS display a prominent stooped-over position, are unable to turn their head from side to side, and walk with a shuffling gait as their spine and SI joints fuse together.

AS tends to mimic the symptoms of “ruptured disk” or “back sprain,” especially in its early stages, which may not be detected on Xray or MRI. I know this from my own experience. Despite a long history of severe and deforming AS among the men the father’s side of my family, my complaints of lower back pain and sciatica in my mid-20’s were “diagonsed” by a neurosurgeon as a “ruptured disc,” for which I underwent a myleogram and t three weeks of lumbar traction in the hospital, and then three epidural blocks in my lower spine before I was sent home with an explanation that my back pain was now “all in my head.”

He steadfastly refused to consider the possibility I was having early stage AS, even though the myleogram (doubly dangerous for me as I am allergic to iodine), showed that the “disc” had “moved back in to position” since his original diagnosis.

Having said all of this, the old medical adage that “if you hear hoofbeats, think of a horse, not a zebra,” is certainly appropriate. But, if the patient tells you that there’s a family history of AS (or related conditions such as psoriatic arthritis), and that the pain is relieved by exercise rather than rest, it’s time to start thinking about the zebra and not the horse.

Fortunately for me, after years of periodic pain, I finally self-referred myself to the arthritis clinic at a major teaching hospital. The doctors there were willing to make the right diagnosis and start me on the right combination of medication, physical therapy and occupational adjustments that have spared me the same level of spinal deformity and disability that AS has caused to other men in my family. These days, newer TNF drugs (e.g., Embrel) are very effective in halting the course of AS in many patients.

As with any other condition, the willingness of the clinician to listen carefully to the patient’s history and symptoms leads to the right diagnosis and treatment.

Lose weight. Not a few pounds but get skinny. What you weighed when you were 18. Then go to the gym and do vigorous treadmill (uphill, not level) and every machine in the joint. I guarantee you will feel better.
-age 68 with old crushed disc, no surgery. 5’11” 165 lbs

Acupuncture and Chinese herbal therapy are among the most effective modalities for the treatment of acute and chronic back pain. Patients usually feel some pain relief even after their first treatment and generally regain mobility at an accelerated pace — all without the inherent risks of pharmaceuticals or surgical intervention. Licensed acupuncturists are usually well trained to make an orthopedic-neurological assessment and refer out for imaging studies should further investigations be advised. The vast majority of back pain sufferers not needing medical intervention will be better — and more cost-effectively — served by a holistic approach that includes acupuncture, herbal therapy, bodywork, appropriate exercise (such as yoga, taichi, etc.) and lifestyle changes.